3800-FM-WSFR0339
8/2005
\COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATER STANDARDS AND FACILITY REGULATION
General Permit Number:
PAG-07 _______
Reporting Period ______
RECORDKEEPING AND REPORTING FORM
PAG-07
A.
General Information:
Permittee’s Name:
Address:
B.
Pollutant Concentrations: Attach analytical results for the following pollutants in the exceptional quality
biosolids that are applied to the land or that is sold, given away or distributed in a bag or other container for
beneficial use.
Arsenic (mg/kg)
Lead (mg/kg)
Selenium (mg/kg)
PCBs (mg/kg)
C.
Cadmium (mg/kg)
Mercury (mg/kg)
Zinc (mg/kg)
Copper (mg/kg)
Nickel (mg/kg)
Molybdenum (mg/kg)
Pathogen Reduction Achieved: Indicate which of the following treatment alternatives was used prior to beneficial
use of the exceptional quality biosolids. For Alternatives 5 and 6, list the specific Process to Further Reduce
Pathogens (PFRP):
Alternative 1
Alternative 2
Alternative 4
Alternative 5:
Alternative 3
Alternative 6:
PFRP
Equiv. PFRP
Briefly describe the biosolids treatment process performed and submit analytical results and/or process data to
demonstrate that the pathogen reduction selected was met:
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3800-FM-WSFR0339
D.
8/2005
Vector Attraction Reduction Performed: Indicate which of the following treatment options was performed prior
to beneficial use of the exceptional quality biosolids:
Option 1
Option 2
Option 3
Option 4
Option 5
Option 6
Option 7
Option 8
Briefly describe the biosolids treatment process performed and submit analytical results and/or process data to
demonstrate that the vector attraction reduction selected was met:
E.
If one of the vector attraction reduction options 1 - 5 in Section D of this form is selected, was the pathogen
reduction treatment alternative chosen in Section C of this form met prior to or at the same time the vector
attraction reduction option chosen in Section D was met?
Yes
No
F.
For the purposes of compliance with terms, conditions, statutes, rules and regulations described in the general
permit (PAG-07):
1.
Exceptional quality biosolids sold, given away or otherwise distributed in a bag or other container:
On the line below, indicate the total amount (dry weight basis) of exceptional quality biosolids sold, given
away or distributed in a bag or other container. For amounts greater than 1.1 dry tons distributed during the
monitoring period to a single recipient, attach a list identifying the name and address of each recipient and
the amount of biosolids distributed.
Total amount distributed:
2.
dry tons
Bulk application of exceptional quality biosolids conducted by Permittee:
Provide the following information when bulk applications of EQ biosolids were conducted by the permittee or
agent for the permittee:
Site Name:
Site Location:
Municipality:
Amount of exceptional quality biosolids land applied
County:
(dry tons)
Description of the beneficial use(s) of exceptional quality biosolids
3.
Application rates: Attach a summary of application records for each field receiving exceptional biosolids
applied by the permittee or agent for the permittee during the reporting year. For agricultural applications,
include the information shown on the attached worksheets (Agronomic Rates).
4.
Training required: Name of certified/trained personnel responsible for the land application activity:
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3800-FM-WSFR0339
G.
8/2005
Certification: I certify, under penalty of law, that one of the Class A pathogen requirements in Title 25 Pa. Code,
§271.932(a) and vector attraction reduction requirements specified in Title 25 Pa. Code, §271.933(b)(1) - (b)(8)
have been met. This determination has been made under my direction and supervision in accordance with a
system designed to ensure that qualified personnel properly gather and evaluate the information used to determine
that the pathogen reduction requirements and vector attraction reduction requirements have been met. I am aware
that there are significant penalties for false certification including the possibility of fine and imprisonment.
NAME AND OFFICIAL TITLE (Use Corporate or Professional Seal As Appropriate):
Name:
Title:
Signature:
Telephone: (
)
Date Signed:
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3800-FM-WSFR0339
8/2005
Agronomic Loading Rate Summary Worksheet
YEAR
SITE NAME
Desired
Crop
Yield
Field
ID
Total
1
2
Acres
Crop
N
Need
Applied
P2O5
Applied
K2O
Calculated
App. Rate
Biosolids
or Septage
Actual
Rate
Applied
Biosolids
Planned
Crop
bu/A
T/A
lb/A
lb/A
lb/A
Application
Method 1
dt/a or gal/acre
DT/A
NA
NA
NA
NA
NA
NA
NA
NA
NA
Surface Application or Injection or Incorporation
Total field septage or biosolids must be reported in dry ton (DT) and either in wet ton (WT) or gallons (Gal)
-4-
Total Field 2
Septage or
Biosolids
Septage or
Biosolids
Application
WT/A
Gal/A
DT
WT
Gal
Total Acres
Spread
Planting
Date
Acres
(e.g., early
May)
NA